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In this episode, Dr. Julie Kroviak and Dr. Beth Winter with our Office of Healthcare Inspections discuss VHA staffing shortages and stress on its workforce based on findings from two published reports. Plus highlights of the OIG's recent oversight work.
Veteran Oversight Now is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode features interviews with key stakeholders, discussions on high-impact reports, and highlights of recent oversight work. Listen regularly for the inside story on how the VA OIG investigates crimes and wrongdoings, audits programs that provide benefits and services to veterans, and inspects medical facilities to ensure our nation’s veterans receive safe and timely health care.
Fred Baker:
Welcome back to another podcast episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I'm your host, Fred Baker.
Each month on this podcast, we'll bring you highlights of the OIG’s recent oversight activities and interview key stakeholders in the office's critical work for veterans.
Joining us today is Dr. Julie Kroviak, Dr. Beth Winter. Dr. Kroviak is the principal deputy assistant inspector general for health care inspections. Dr. Kroviak has also served as the senior physician in the office of Health Care Inspections here. Before joining the OIG, she served as the medical director of the Washington, DC, VA Medical Center, Fort Belvoir community based outpatient clinic for 11 years.
Dr. Winter is a psychiatrist located in our Baltimore Office of Health Care Inspections. Dr. Winter has worked in private practice, community settings, and in academia and was the co-director of the Johns Hopkins hospital anxiety disorders clinic. Dr. Winter joined us in 2018.
Welcome, Dr. Kroviak, Dr. Winter. Thanks for joining the podcast today.
Dr. Julie Kroviak:
Thanks for having us.
Dr. Beth Winter:
Thank you.
Fred Baker:
Okay. Today we're discussing the topic of VHA staffing shortages and the stress on its workforce. Through this, we're looking at two recent OIG reports: OIG Determination of VHA Occupational Staffing Shortages for Fiscal Year 2022 and the report the VHA Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID 19 Pandemic.
This topic is very timely given the recent news headlines declaring a national shortages of health care workers across the industry, especially in the nursing occupation. I read recently in one medical report that it's anticipated that the US will need another 1.2 million nurses by 2030 just to address the demand of the current shortage.
Dr. Kroviak, can you provide a general overview of why we do the staffing report and our findings in the most recent report?
Dr. Julie Kroviak:
Certainly. So, we're actually congressionally mandated to put out this report. But it is really important to inform stakeholders what local VA leaders are saying. They have defined as critical staffing shortages, and they do this in both clinical and non-clinical positions, as both are obviously incredibly important to keep a hospital running.
Fred Baker:
You had mentioned before that a shortage is not necessarily a vacancy. Can you describe that difference real quick for the audience?
Dr. Julie Kroviak:
Yeah. So, vacancies will be related to what a facility is already authorized to hire, but they may not list that as a critical shortage. So, you could have 50 vacancies in pharmacy, but the facility, for a wide variety of local reasons, may not identify that as their most critical shortage.
Fred Baker:
So, the critical shortages are exactly what they say they are. They're what the hospital needs most.
Dr. Julie Kroviak:
Yeah. I mean, there's criteria that goes into to define it within the CFR and those tend to be definitions that are specific to geographic regions where you find it's really, really difficult to hire and retain certain types of workers.
Fred Baker:
Gotcha. And what was different about the findings in this report from some of the reports in the recent past.
Dr. Julie Kroviak:
Though not necessarily surprising, but disappointing. This is the first time in five years that we've seen an increase in the number of reported critical shortages, and that's likely due to what's been going on in medicine and health care delivery due to the pandemic.
Fred Baker:
And give us the range of the types of staffing shortages, the occupations.
Dr. Julie Kroviak:
And so, as always, the top trend to be providers like independent providers. And in this case, no surprise, it's mental health providers. We see that almost every year. And that's not unique to VHA, but also nursing support, nursing and nursing support. And then on the non-clinical side, custodial workers took the lead hands down as a critical shortage across the facilities.
Fred Baker:
And you just mentioned that it was initially unique to VHA. How do these staffing shortages compare to the private sector? I know wasn't part of this report, but as a physician, how do these compare to the private sector? Are they suffering as well?
Dr. Julie Kroviak:
Yeah. So, the health care industry has suffered enormous drops because of the pandemic, and it's really tested resiliency on many fronts of every health care delivery system. So, when we talk about mental health provider shortages, that's not a unique VA issue. I would argue VA has a unique demand for these services based on the histories of service of veterans, and most importantly, that increased risk of suicide in veterans that we see when we compare it to the civilian community. So that preexisting need has been exacerbated dramatically by the pandemic.
Fred Baker:
So, is the pandemic the main thing that's behind these shortages? Are there other factors?
Dr. Julie Kroviak:
So, it's multifactorial, for sure. VHA has always struggled to compete with compensation that the private sector can offer, especially in your most highly rural regions. And when they do effectively recruit the talent they need, they've got some issues with onboarding process. So, there are incredible administrative burdens to bringing on new staff within the department, and it can often take many months. And by that time, the candidate you really wanted has likely walked away and taken a job at another health care facility that can put them to work right away.
They've been undergoing an effort to modernize their HR processes, but it's been really complicated. And we have teams in our audit division that are repeatedly digging in to understand the processes that are interfering with more reasonable onboarding times.
Yeah, I'd be remiss to also mention the pandemic. It introduced a lot of burnout, more than ever before, and that also drives shortages.
Fred Baker:
You mentioned just a minute ago how critical to the mental health occupation was to veterans in preventing suicide. Overall or generally speaking, what implications do these staffing shortages have on VA care? And you mentioned a few, but the challenges specific to VA. with respect to filling those positions. You mentioned the onboarding and the pay.
Dr. Julie Kroviak:
Yeah. So, staff shortages can always increase risk to patients at hospitals. It can dramatically increase risk to patients. They contribute to delays in care. They increase the fatigue among the staff that's left behind, and that is an opportunity for fatigue staff to introduce errors into care, to put other oversight activities related to quality on the back burner while they actually deliver care because they don't have the staff to do both at the same time. And that's a pretty threatening cycle. A fatigued staff often leaves, and then you back in the cycle of chasing your tail, trying to hire, trying to retain, exhausting the staff you had, and putting patients at risk potentially.
Fred Baker:
Is there a solution or is the VA stuck, you know, muddling through the next few years or until 2030 with fewer qualified staff who are overworked and stressed out?
Dr. Julie Kroviak:
So, it is a concerning trend we're seeing. And health care is in need of innovation like never before. And VHA actually has a significant history in investing in telehealth technologies. Recent work from this office showed that when the pandemic hit, they mostly pivoted to the telephonic venue, so not really leveraging their video capabilities like we would have expected. Reconsidering how they can get staff and veterans more comfortable in navigating this technology could allow VA to better tap into resources on a broader scale.
I use the example of a patient in Montana needing a dermatologist. Well, perhaps the Miami dermatologist can use this technology to provide care to that veteran in a more rural location. But that takes a few things like the technology, broadband, veteran education so they're comfortable with using that type of venue. And then retention of the current staff is also critical. If you don't respond to this fatigued staff and their physical and mental health needs, you are going to lose people.
This concept of “physician heal thyself” really only works in the system that advocates for its staff and encourages what they need to support their mental and physical health care needs while they deliver care to veterans.
Fred Baker:
Thank you. I'll go to Dr. Winter real quick. Dr. Winter, you released a report about the stress on the VHA workforce caused by the pandemic. Talk a bit about that report and its findings.
Dr. Beth Winter:
Sure. So, part of the reason that we decided to look into this issue to begin with is the fact that we knew that the pandemic was going to create a surge in mental health needs, not only for the general public, but specifically for healthcare workers.
And the reason we knew that was because of the SARS epidemic, you know, way back in 2003, almost 20 years ago now. After that epidemic, health care workers experienced increased rate of depression, of PTSD, increased rates of substance use disorders, all of which potentially contributed to burnout, decreased work performance for many years after the epidemic ended.
And there were a lot of studies showing that, as Dr. Kroviak mentioned, organizations that prioritize their healthcare workers’ mental health and mental well-being had decreased rates of turnover, decreased rates of employee burnout, and their health care workers seemed to do better overall.
Whereas organizations that had a much more sort of stoic approach to their employees’ well-being had issues like decreased reporting of safety concerns, decreased organizational resilience, increased worker stress. And so we wanted to know how VHA was going to manage this with their own health care workers.
I want to lead by saying VHA did a lot of good things. You know, they did a lot of things right. They had a very short period of time in which to create and disseminate information to try to help this staff do their best during very trying times.
And so NCOD, or the National Center for Organizational Development, created a COVID 19 rapid response consultation process for VHA leaders who could contact NCOD and ask for advice or help on how to support their staff through this pandemic.
The Organizational Health Council very quickly set up a COVID 19 tiger team that created a employee support tool kit that leaders could use to develop processes and resources for their employees. And then there were several VHA central offices that independently created and disseminated employee resources.
So, they were doing a lot of things well and very quickly at the beginning. Unfortunately, what we found in our report was that even though they were creating these things and doing their best to disseminate them, people just didn't know that they were out there. It seemed like the further away you got from national sort of organization and hierarchy, the less people seemed to be aware that these resources even existed. So, what we found was that 81% of VISN respondents knew about these resources. Ninety-one percent of facility directors knew, which was good news. But then only 60% of facility service line leaders knew. And then only 40 to 45% of that frontline staff knew that these resources were available to them. Even those people who did know that these things were out there and existed, they didn't really use them. There was extremely low utilization across the enterprise, which was very concerning as well. So, if 40% of clinical staff were aware that things these things existed, only one in four of those people went ahead and utilized the resources.
So, people just weren't making use of these incredible things that were available to them.
Fred Baker:
Was there any indication, though, as to why? I mean, was it was it time? Were they stressed and didn't have the time? Or were they skeptical? Was there any indication as to why they only one in four.
Dr. Beth Winter:
So, there was a really wide variety of reasons. Some of it was simply that they felt they didn't have time, that they felt so overworked and under-resourced that they weren't able to step away from their work in order to sort of take care of their well-being.
Some of them were skeptical. One of the resources that was promoted most heavily was the use of employee assistance programs. But, at least originally, they would only be three sessions approved and most of the staff who were encouraged to use EAP, it didn't feel like that was enough. And so there was a sense of why bother?
So, there were there were a variety of reasons as to why they didn't utilize the resources.
Fred Baker:
So, the workforce is already stressed from the pandemic, and now it's suffering from staffing shortages. What's the potential impact of combining those two stressors?
Dr. Beth Winter:
I think you can imagine that, you know, sort of the combination of the two could be pretty significant. One of the things that we found as we were talking to people, you know, doing this report was that even prior to COVID 19, there didn't really exist an infrastructure that was sufficient to manage employee health and wellness during these kinds of stressors on the system. So, it wasn't necessarily that the COVID 19 pandemic created such a massive need that it overwhelmed the resources available. It's more that the COVID 19 pandemic sort of uncovered the fact that there didn't exist a system that would have taken care of these needs necessarily in the first place.
So, I think people were probably already feeling the impact of staffing shortages and resource shortages and things like that. COVID 19 has come along to exacerbate all of that, and VHA is right now trying to play catch up in ways to not only take care of the people they have, but to try to attract more.
Fred Baker:
So, then the very similar question I asked Dr. Kroviak as far as what what's the way ahead for VHA on hiring, what's the way ahead for VHA with mitigating this stress factor?
Dr. Beth Winter:
So VHA has already created what they're calling the REBOOT task force, and that stands for reducing employee burnout and optimizing organizational thriving. So, they created that back in November 2021. So almost a year ago now, and they've spent the last nine to ten months basically in a listening process. They've been reviewing the All Employee Survey results. They've been speaking to subject matter experts. They've been doing a lot of their own survey work to try and discover what people's priorities are, and they're really doing their best to listen.
So actually, just last week, they sent out an email from the secretary's office saying that they've chosen their six or seven priorities that they're going to be focused on for the next fiscal year with an emphasis on employee well-being and making them not just something that gets discussed during times of stress, but something that gets prioritized all the time to try to kind of build an organizational resilience that people can fall back upon during periods of stress. And I think, should they be able to accomplish that, I think that kind of messaging is going to be really impactful for the workforce. They want to know that they're being heard, and they want to know that this isn't going to be something that disappears when we stop talking about the pandemic or when we stop talking about these kinds of external stressors, but something that's going to be there for them in the long haul.
Fred Baker:
Thank you. So, to both of you, we are the VA Office of Inspector General. How does this shape your perspective on future oversight? What do we need to be looking at from the perspectives of staffing and quality of care and workforce well-being?
Dr. Kroviak?
Dr. Julie Kroviak:
Sure. So, every project we do always inspires other ways that we can look in future projects. But this is again a leadership story. So, to point to Dr. Winter's work, we can start testing leadership. What is their local knowledge of what tools are available to support their staff? Are they using them? Are they disseminating that information to their staff? And we can measure if staff is able to take advantage of those resources. And if they're not, we can start digging deeper to understand the whys of that.
So, I think we can be a really useful tool for the department in supporting the use of these resources for their fatigued and overwhelmed staff, because it definitely ties to quality of care that veterans are receiving.
Fred Baker:
Dr. Winter, any additional thought?
Dr. Beth Winter:
I think just to further support what Dr. Kroviak is saying, it's really about context, right? When we go in there to do an inspection because there's been some kind of allegation, or even when we're doing a prospective inspection like our cyclical reviews or something like that, having context and understanding the why of things happening is really important to us, and that's going to allow us to make more impactful recommendations. And the employee well-being and the employees’ stressors and forms part of that context.
So, I think we're going to have to start discussing how we can better incorporate that.
Fred Baker:
Dr. Kroviak, Dr. Winter, thank you again for joining the podcast for this very critical conversation. Now I'll turn it over to cohost Adam Roy for this month's highlights.
Adam Roy:
Thanks, Fred. Now, I’ll highlight some of the work the VA OIG completed in August 2022.
I’ll start with some updates to investigations by our agents.
For the first update, a former social worker at the Providence VA Medical Center in Rhode Island fraudulently claimed to be a wounded US Marine Corps veteran who was the recipient of a Purple Heart and a Bronze Star. The defendant collected more than $250,000 in benefits from veteran-focused charities using the personally identifiable information of an actual Marine to falsely claim she served in the Marine Corps from 2009 to 2016, achieved the rank of corporal, was wounded in action, and was honorably discharged. The defendant also falsely claimed to have cancer due to her alleged military service after using her position to access the VA medical records of a veteran cancer patient. The former social worker pleaded guilty in the District of Rhode Island to wire fraud, aggravated identify theft, fraudulent representations about receipt of military medals or decorations, and forging military or naval discharge documents.
Next, a multiagency investigation resolved allegations that a private helicopter flight instructor training company and a community college violated the False Claims Act by making false statements to VA in connection with their jointly operated training program. To qualify for Post 9/11 GI Bill funding, a school is required to certify to VA that no more than 85 percent of the students for any particular course are receiving VA benefits. This requirement, commonly referred to as the “85/15 rule,” is intended to prevent abuse of GI Bill funding by ensuring that VA is paying fair market value tuition rates since at least 15 percent of the students would be paying the same rate with non-VA funds. The investigation alleges that the defendants falsely certified compliance with the 85/15 rule because the flight instructor program included certain expensive classes that were taken almost exclusively by veterans. To reach the required 15 percent threshold, the community college allegedly counted part-time students enrolled in only one online class per semester as full-time students, in violation of VA rules. The defendants agreed to pay $7.5 million to resolve these allegations. The investigation was conducted by the VA OIG, US Attorney’s Office for the District of Kansas, and the Fraud Section of the Department of Justice Civil Division’s Commercial Litigation Branch.
Lastly, following a hotline complaint, a VA OIG investigation brought to light that a veteran exaggerated his mental and physical impairments to fraudulently increase his VA compensation benefits. The veteran lied on a mental health test by reporting to VA that he had been in combat, qualifying him for posttraumatic stress disorder benefits. Investigators confirmed that the veteran was a competitive bodybuilder who faked physical ailments to VA examiners, including using a cane at the VA medical center and telling examiners he could not lift more than 10 to 20 pounds. The veteran was sentenced in the Southern District of Florida to one year of imprisonment, three years of supervised release, and restitution of about $246,000 after previously pleading guilty to theft of government funds.
The VA OIG published nine reports in August. Of note, the VA OIG reviewed VA’s governance of identity, credential, and access management processes as well as audited VHA’s digital divide consult process. Find both of these reports on the OIG website.
In another report titled, “Improved Processing Needed for Veterans’ Claims of Contaminated Water Exposure at Camp Lejeune,” the VA OIG conducted a review to determine whether VBA staff followed regulations when processing and deciding claimed conditions potentially associated with contaminated water exposure at Camp Lejeune, a US military training facility. From August 1953 through December 1987, the Agency for Toxic Substances and Disease Registry estimated one million individuals could have been exposed to contaminated drinking water at Camp Lejeune. In March 2017, VA established a presumption of military service connection for eight illnesses related to veterans’ exposure to that contaminated water.
Based on a statistical sample, the OIG estimated that of 57,500 Camp Lejeune–related claims for VA disability compensation benefits decided during the review period, which was March 14, 2017, to March 31, 2021, VBA staff incorrectly processed 21,000. The two main errors were prematurely denying claims by not sending required letters to veterans requesting evidence needed to document exposure and assigning incorrect effective dates for benefit entitlement. Approximately 1,500 additional incorrectly processed claims involved technical or procedural errors. Premature denial of claims increased the risk that some veterans did not receive the benefits to which they were entitled, and veterans were underpaid at least $13.8 million in benefits over nearly four years because VA regional office staff did not assign the earliest effective date for benefits entitlement.
The OIG found that errors were less likely to occur at the Louisville Regional Office, which processes most Camp Lejeune–related claims, as staff from other VA regional offices lacked experience processing these claims. The OIG recommended that VBA centralize all Camp Lejeune–related claims processing at the Louisville Regional Office or implement a plan to mitigate the error rate disparity with other regional offices. VBA should also conduct targeted quality reviews of Camp Lejeune–related claims from all regional offices processing these claims.
In another benefits-related report, the OIG determined the VBA did not always adjust compensation and pension benefit payments for veterans who were fugitive felons. For example, VBA did not process fugitive felon cases in 2012 and 2013. Also, due to inadequate monitoring, it did not process about 46 percent of fugitive felon cases referred by the OIG in 2019 and 2020. As a result, some veterans may have received funds to which they were not entitled. In addition, due to a previously unnoted deficiency with VBA’s automated letters, some veterans were not informed of their legal rights and potentially had their benefits improperly suspended. VBA concurred with the OIG’s three recommendations, which were (1) review unprocessed felony referrals, (2) improve monitoring procedures, and (3) ensure necessary information is provided to veterans. VBA provided information on the actions taken to address these recommendations, and based on this information, the OIG considers recommendation two closed.
The last report I’ll share was published by OIG’s Office of Healthcare Inspections.
Here, the VA OIG conducted a healthcare inspection to assess allegations of a suspicious death of a community living center resident and quality of care issues at the VA Greater Los Angeles Health Care System in California.
Specifically, the allegations were that nursing staff failed to assess the resident, who was complaining of pain; properly document assessments of the resident, reassessments, and treatments or interventions; and follow and implement the provider’s order related to transferring the resident to a higher level of care.
The OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. However, the OIG did not substantiate that other individual nursing staff members involved with the resident’s care failed to properly document the resident’s care. The OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the emergency department but was unable to determine if this impacted the patient’s outcome.
The OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the community living center.
Ultimately, the OIG made 10 recommendations. The report titled, Failure to Communicate and Coordinate Care for a Community Living Center Resident at the VA Greater Los Angeles Health Care System in California, was published on August 17th and available for download on our website.
Before I wrap up today, I’d like to share a relatively new feature on our website. Check out the VA OIG’s Fraud Toolkit and Crime Alerts. The VA OIG investigates a wide range of potential crimes—from financial crimes to threats against VA personnel and property to actions associated with patient harm. The toolkit provides a list of key possible indicators specific to various types of fraud. The list is far from exhaustive, but it does identify common signs that VA personnel, contractors, and the veteran community—and maybe some of you listening out there as well—should be aware of in order to report suspicious activity and alleged wrongdoing to the OIG hotline. Examples of potential indicators include compensation benefits fraud, healthcare fraud, public corruption and kickbacks, and fraud related to public health crises, like we have seen recently with the pandemic. You can find this toolkit right on our home page.
Stay tuned for more highlights next month. Thanks for turning in!
This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers, through meaningful independent oversight. Check out the website for more on the VA OIG oversight mission, read current reports, and keep up to date on the latest criminal investigations. Report potential crimes related to VA; waste or mismanagement; potential violations of laws, rules, or regulations; or risks to patients, employees, or property to the OIG online or call the hotline at 1-800- 488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800- 273-8255, press 1, and speak with a qualified responder now.